Febrile illness in children 2021

How to make a diagnosis of febrile illness in children in a developing country

1. Febrile Illness
in
Children
Types, Clinical Features, Diagnosis
Complications, Management and Prevention
Prof. Imran Iqbal
Fellowship in Pediatric Neurology (Australia)
Prof of Paediatrics(2003-2018)
Prof of Pediatrics Emeritus, CHICH
Prof of Pediatrics, CIMS
Multan, Pakistan

2. (God speaking to Prophet Muhammad (PBUH)
And remember our prophet Ayub(Job), when he called his Lord:
“Indeed I have been afflicted with distress (illness),
and You are the Most merciful of all those who are kind”
Al Quran surah Al-Anbiya21:83

3. Clinical Case Scenario
•An 8 year old child presents with fever for the last 5
days.
•Fever rises in the evening
•Child is not active as before
•His appetite has decreased
•On examination, his temperature is 104 F
•How will you further evaluate this child to make a
diagnosis and decide aboutmanagement ?

4. How Body Temperature is maintained ?
CORE BODY TEMPERATURE
is regulated by
HYPOTHALAMUS
to be within the normal range
by controlling the mechanisms of
Heat production and Heat loss

5. Mechanisms of Regulation
Heat Production
•Body metabolism
•Muscle activity
•Shivering
•Vasoconstriction
Heat Loss
•Respiration
•Convection
•Vasodilatation
•Sweating

6. Pathophysiology of Fever
•Fever occurs when there is change in setting of
regulatory center or thermostat located in the
hypothalamus
(by endogenous pyrogens= IL1, IL6, TNF)
•Fever can also result from failure of regulatory
mechanisms due to very high environmental
temperatures
(Heat stroke during summer season)

7. How to measure Body Temperature in Children
CORE body temperature
Older Children
•Thermometer in mouth (under the tongue) for ½ minute
Infants & Small Children
•Thermometer in AXILLA for 2 -3 minutes
(Do NOTadd anything to the measurement)
Both of these are almost equal and give CORE body temperature
Other Methods
•Infra Red Thermal device (usually forehead temperature is taken)
•Rectal temperature (higher than oral temperature)

8. FEVER
•Normal Body Temperature = 37 C
Normal Body Temperature = 98.6 F
•Range of Normal
(36.5 C to 37.5 C)
(97.5 F to 99.5 F)

9. Grading of Fever
•Low Grade Fever37.5 –39 C
99.5 –102.5 F
•High Grade Fever39 –40.5 C
102.5 –105.5 F
•Hyperpyrexiamore than 40.5 C
more than 105.5 F

10. Fever in Children
•During rising fever trunk will be warm and extremities
cold
•During stable fever, whole body will be warm
•Shivering accompanies rapid rise of fever
•Shivering can occur in all febrile illnesses and is not
specific for any cause or diagnosis

11. Is fever Beneficial for human body?
•Fever is an important clinical symptom and sign of
illness
•During fever, immune function of leukocytes is
increased
•More lymphocyte proliferation and cytokine
production
•Growth of infectious microorganisms is inhibited
(decreased)

12. Harmful effects of fever?
•During fever, Oxygen demand and O2 consumption is
increased
•Children are irritable and anorexic during febrile episodes
•Febrile convulsions (fits during sudden rise of fever) can occur
in children below five years of age
•Hyperpyrexia can compromise cardio-respiratory and
metabolic functions of the body and can damage the brain

13. How to Evaluate and Manage the child with Fever ?
•Initial assessment
•History
•Examination
•Diagnosis
•Investigations if needed
•Management

14. Brief Initial Assessment –Severity of Illness
•Unable to drink / Vomiting everything
•Dehydration
•Lethargic or unconscious
•Convulsions
•Airway & Breathing –Respiratory rate, Cyanosis
•Circulation –Heart rate, Capillary refill, Peripheral Pulses
•Vital signs –Pulse, Respiration, Temperature
•Oxygenation –Pulse Oximeter Oxygen Saturation

15. History
•How much Fever was present on day 1, day 2, day 3 ?
(gradual or sudden rise?)
•Does the child have associated symptoms of ?
-cough, breathing problem
-vomiting, diarrhea
-skin rashes
-headache, convulsions / fits
-burning micturition
-pain anywhere in the body ?

16. Technique of Physical Examination
•Inspection
•Auscultation
•Palpation

17. Physical Examination of Child
•Dehydration
•Skin rashes
•Respiration, chest indrawing
•Cardiac & chest auscultation
•Eyes –conjunctivitis, jaundice, anemia
•Oral cavity –thrush, ulcers
•Lymph nodes
•Liver, spleen
•Signs of meningeal irritation
•Throat, ears

18. Diagnosis
and
Differential Diagnosis
Classify differential diagnoses
10 common clinical problems

19. Diagnosis of Child with FEVER
(10 common clinical problems)
•URTI –Runny nose, Cough, Flu
•ENT –Sore throat, Ear pain
•Respiration –Cough, Fast breathing, Chest indrawing
•GIT –Vomiting, Diarrhea, Pain abdomen
•Liver –Pain abdomen, Vomiting, Jaundice
•CNS –Headache, Vomiting, Convulsions, SOMI
•Skin –Skin rashes, Swellings, Lymphadenopathy
•Urinary –Burning micturition
•Musculoskeletal –Pain and swelling of joints
•Systemic –No localizing signs, Splenomegaly

20. Fever + URTI symptoms and signs
Runny nose, Cough, Flu
•Fever (low) + Runny nose + cough =
Acute Rhino-sinusitis,
ARI (cough and cold)
•Fever (high) + Runny nose + cough = Influenza

21. Fever + ENT symptoms and signs
Sore throat, Ear pain
•Fever + Sore throat + inflamed tonsils = Acute Tonsillitis
•Fever + Sore throat / diffuse redness = Viral Pharyngitis
•Fever + Ear pain / Ear discharge = Otitis media

22. Fever + Respiration symptoms and signs
Cough, Fast breathing, Chest indrawing
•Fever + Cough
AND
•Fast breathing / Chest indrawing
OR
•Inspiratory coarse crepitations
OR
•Bronchial breath sounds
Pneumonia

23. Fever + GITsymptoms and signs
Vomiting, Diarrhea, Pain abdomen
•Fever + Vomiting + Diarrhea = Acute Gastroenteritis
•Fever + blood in stool = Dysentry
•Fever + Pain abdomen + tenderness = Appendicitis,
= Peritonitis

24. Fever + Liversymptoms and signs
Pain abdomen, Vomiting, Jaundice
•Fever + Pain abdomen + Jaundice =
Acute Hepatitis

25. Fever + CNS symptoms and signs
Headache, Vomiting, Convulsions
•Fever + Fits / Unconsciousness = Meningitis,
= Febrile seizures
= Encephalitis
= Cerebral malaria
•Fever + SOMI = Meningitis
•Fever + Bulging Fontanel = Meningitis,
Intracranial Hemorrhage

26. Fever with Skin Rashes
•Fever + Cough + Maculopapular Rash =Measles
•Fever + Vesicular Rash = Varicella
•Fever + Purpuric Rash = Meningococcemia
•Fever (low grade) + Macular Rash = Rubella
•Fever (subsided) + macular rash = Roseola infantum

27. Fever with Swelling / Lymphadenopathy
•Fever + soft tender subcutaneous swelling = Pyogenic Abscess
•Fever + soft non-tender swelling = Tuberculous (cold) abscess
•Fever + Parotid enlargement = Mumps
•Fever + tender enlarged lymph nodes = Acute lymphadenitis
•Fever + chronic non-tender lymph nodes = Tuberculosis
= Lymphoma
•Fever + lymphadenopathy + Purpura = Acute Leukemia

28. Fever + Urinary symptoms and signs
Pain, Burning micturition
•Fever + Pain + Urine problems = UTI

29. Fever + Musculoskeletalsymptoms and signs
Pain and swelling of joints
•Fever + Limping Gait = Osteomyelitis
= Pyogenic Arthritis
•Fever + Pain + swelling in joints
= Rheumatic Fever
= Juvenile Idiopathic Arthritis
•Fever + Spine deformity = Spinal tuberculosis

30. Fever + Systemic illness
Splenomegaly
•Fever + Splenomegaly = Malaria,
= Typhoid
= Sepsis

31. Fever + Systemic illness
No localizing signs
•Fever + No localizing signs =
= Bacteremia, Septicemia
= Typhoid
= UTI
= Malaria

32. (PUO –Pyrexia of Unknown Origin)
Prolonged Fever (more than 14 days)
•Prolonged Fever (more than 14 days) =
= Typhoid
= Tuberculosis
= Rheumatic diseases / JIA
= Auto-immune diseases / SLE
= Lymphoma / Leukemia
= AIDS

33. Common Differential Diagnosis of Fever in Children
•Runny Nose, Cough –(Rhinitis, Flu)
•Sore Throat –(Pharyngitis, Tonsillitis)
•Ear Pain –(Otitis Media)
•Fast Breathing –(Bronchitis, Pneumonia, Asthma)
•Vomiting, Diarrhea –(Gastroenteritis, Hepatitis)
•Pain Abdomen, Vomiting –(Appendicitis, Mesenteric Adenitis)
•Headache, Convulsions –(Febrile Fits, Meningitis, Encephalitis)
•Skin Rashes –(Measles, Varicella, Roseola Infantum)
•Burning Micturition –(UTI)
•Pain And Swelling Of Joints –(Arthritis, Osteomyelitis, JIA)
•No LocalisingSigns –(Sepsis, Typhoid, Malaria, UTI)
•PUO –(Typhoid, Tuberculosis, Lymphoma, SLE)

34. Investigations in the Febrile Child
(as needed guided by clinical features)
•CBC (Hb, TLC, DLC, platelets)
•CRP
•X-ray Chest
•USG abdomen
•Liver function Tests
•Urine Examination
•Renal Function tests
•ICT Malaria
•Typhidottest
•Specific Serological tests –
--antigen detection (ICT, PCR)
--antibody detection (IgM, IgG)
•Blood / Urine / Fluid cultures
•CSF examination
•CT / MRI scans
•Biopsy

35. How to Diagnose Infectious Diseases ?
Organism Detection (confirmatory)
•Detect the Organism -Bacterial / Viral Culture and Sensitivity
•Find the DNA / RNA -PCR (Hepatitis C, GeneXpertfor
tuberculosis, Covid19)
•Check for Specific Antigen -ICT / ELISA (RDT for malaria,
HBsAg,)
Antibody detection (IgM recent infection, IgG past infection)
(antibody detection has variable Sensitivity and Specificity)
•Specific IgG or IgM –HBsAb, HBcIgM, Dengue IgM, Typhidot
•Antibody assays (not reliable) -Widaltest, TB Mycodot

36. Management of the Febrile Child

37. Management of the Febrile Child
•Symptomatic Management
•Supportive Management
•Specific Management
•Manage Complications

38. Symptomatic Management for Fever
•Do not over-wrap the child
•Antipyretics for Fever
Paracetamol= 10 –15 mg/kg
Ibuprofen = 5 –10 mg/kg
•Sponging with water

39. Nutritional Management of the Febrile Child
•Give Extra Fluids
•MAINTAIN CALORIC INTAKE
•Small frequent feeds of soft, palatable diet
•Give usual diet which the child likes. Do not restrict any food
•IV Fluids if frequent vomiting, severe anorexia or hypoglycemia

40. Specific Management of the Febrile Child
•Treat the cause after the clinical / laboratory diagnosis
•Follow standard treatment guidelines for different diseases
•Avoid inappropriate use of Antibiotics which is the most
important reason for anti-microbial resistance
•Viral infections, cough and cold and diarrhea do not need
antibiotics

41. Choice of Antibiotics for Infections
•For infections, Consider:
1. focus of infection
2. likely infecting micro-organisms at the site of infection
3. antibiotics which are effective against these micro-organisms
4. local resistance pattern of micro-organism
Choice of Antibiotic for an infection depends upon
•Severity of illness
•Route of administration -Oral or IM or IV antibiotics
•Phamacokineticsof medicine
•Adverse effects of antibiotics

42. PREVENTION

43. Protection against Infections
•Vaccination
•Handwashing
•Use Masks
•Social distancing
•Unpolluted air
•Breastfeeding
•Adequate Nutrition
•Micronutrients
•Safe water
•Clean food and Milk

44. EPI Pakistan gives Protection against following
10 Diseases
•Tuberculosis
•Diphtheria
•Pertussis
•Tetanus
•Hepatitis B
•Polio
•Rota virus
•Pneumococcal diseases
•Hib
•Measles

45. Other Vaccines available in Pakistan
•Measles, Mumps, Rubella
•Varicella
•Hepatitis A
•Typhoid
•Meningococcal vaccine
•Influenza
•Covid19

46. Medical Profession

47. Thankyou